Friday, 9 April 2010

Encouraging news

Some of the doctors at a recent Wellington conference on organ transplantation favour compensation for donors or even encouraging importing purchased organs.

Paying people $5000 to part with their kidneys would help tackle poor organ donor rates, a health expert says.

Auckland Renal Transplant Group clinical director Stephen Munn said yesterday that health officials should look at following Iran's lead with the "commercialisation" of organs harvested from living donors. New Zealand has one of the lowest organ donor rates.

He spoke out as the Future of Organ and Tissue Donation seminar began at Victoria University.

Work and Income currently pays living donors up to 12 weeks' sickness benefit and some related costs during and after the operation.

Professor Munn proposed that New Zealanders who donated part of their liver or a kidney receive an incentive of about $5000 as well as expenses. "We should have the balls to think about it," he said.

Professor Rosman, a speaker at a conference on NZ's low organ-donor rate held in Wellington yesterday, said he did not approve of the practice and would never recommend it, but there was no point in ignoring it.

He proposed allowing people to buy organs, but setting up a safe hospital in a Third World country so they could receive healthy organs and be well cared for.

Professor Rosman said it was easy to find kidneys for sale through the internet.

"The problem is, we don't know where it happens - it's usually small hospitals in the bush and people get bad kidneys, they may get HIV ... We've seen it in the past.

"But if you could save your family by selling an organ and you could do that in a proper hospital and you know you would be seen every half-year after your surgery and have proper controls and be safe and not be fobbed off with $100 [instead of the promised $10,000 payment] ...

"I think in the end that's a better system, otherwise we're just fooling ourselves."

Sensible.

The Radio New Zealand spot on the conference made a few nice points, including that the "Gift of Life" slogans do more to shut down rational debate than they do to encourage altruistic donation.

Maybe we'll yet see some progress.

MacDoctor also supports cadaveric sales. I of course agree with him that this is best done with prior consent. He also emphasizes that the public health system ought to be able to bid for organs in such a system; I suppose I'd taken this as obvious, but it's well worth noting.

MacDoctor worries slightly that allowing commercialized live organ transplant may violate physicians' duty to do no harm. Fortunately, the best evidence now suggests that there's no harm done if the transplants are done in good conditions with adequate follow-up care for donors. The more we effectively force folks to go overseas, the more we ensure that donors are treated poorly. I'd prefer things be done entirely here, but Professor Rosman's suggestion noted above also seems a very nice solution.

But MacDoctor's bigger worry is about exploitation. I'd again note that the worst cases he's suggesting are rather unlikely if transplants are done here*, but Rosman's suggestion also ought to be able to avoid the more potentially troubling forms of exploitation. I'm unsurprisingly untroubled by the more minor forms of exploitation, like MacDoctor's "How ethical would it be to take part of the liver of a man with a gambling addiction in return for wiping his debt?" There are all kinds of similarly exploitative transactions that take place regularly, with fewer beneficial consequences. Folks entering prostitution or taking on high mortality risk jobs because of financial pressure, for example. Last I'd checked, mortality rates among fishermen was higher than mortality rates for live kidney donors; for liver lobe donors, I think the rates were comparable. Why would it then be morally unacceptable to let someone take on a risk that helps to save someone else's life in exchange for money but morally acceptable to let someone take on a very similar risk that helps us get tasty fish in exchange for money?

I'm happy though to second MacDoctor's call for an organ donor registry, legally binding, and instantly available to medical folks who need to make a quick call on whether to start harvesting. But if that, plus increased promotion of organ donation, plus opening a market in cadaveric organs, plus LifeSharers isn't enough to knock out the waiting list, I hope we can give a regulated market a second look.

*I'm imagining, of course, the relevant Green Party "Buy New Zealand Made" campaign.

Really great to see that New Zealand is making some progress on this front, though clearly many superstitions about exploitation remain.

Something about the idea of organ transplantation really makes people's economic thinking go completely haywire. It seems to go well beyond the usual projection of a worst-case market scenario contrasted with a best-case government-regulation scenario. I've repeatedly heard the ignorant presumption, confidently expressed, that signing an organ donor card is akin to signing your own death certificate, as doctors would supposedly hasten your death after a minor accident in order to harvest your organs. And there's the urban legends about being knocked out and waking up in a hotel bathtub full of ice with your kidneys removed. If these are the hysterical sentiments people conjure up in the absence of organ markets, it's easy to see why the very idea of attaching monetary value to organs shuts people's brains down entirely.

@Moatz: some of MacDoctor's concerns I'd share. I'd hate to see folks be ripped off through breach of contract: promised ongoing care which then wouldn't be provided. I can imagine this happening in places where poor folks have little access to what weak formal legal systems there are. And so it wouldn't bother me at all for a Kiwi company to set up its own hospital in India (or whereever) and be subject to Kiwi oversight.

I'd also agree with him that there would be something very troubling about folks being offered cash to off themselves for a live heart transplant. But, I find it a pretty unlikely event if we have the increase in cadaveric donation we could get with legalized trade and compensation for cadaveric donation.

@Lats: It's a trivial amount relative to the cost of surgery. All the folks who agonize about poor folks being priced out of the market forget that a transplant operation costs about $100K anyway, borne by the public health system. A 5 or 10 percent price increase in cost in order to save a whole lot of lives - pretty easy call I'd say.

"I'd hate to see folks be ripped off through breach of contract: promised ongoing care which then wouldn't be provided."

thats a problem with the legal system (and the government therefore) itself not the actual act of poor people selling their organs which is what the professor and MacDoctor are against and what a lot of people conjure notions of exploitation about.

"I'd also agree with him that there would be something very troubling about folks being offered cash to off themselves for a live heart transplant."

thats a very speculative argument. We have to go by actual evidence when we're considering new things.